Use Of Rotational Thromboelastometry Research Articles

The use of Rotational Thromboelastometry (ROTEM) in Adult Cardiac Surgeries: Review Article

The use of Rotational Thromboelastometry (ROTEM) in Adult Cardiac Surgeries: Review Article

Prevalence and predictors of hypercoagulability detected by rotational thromboelastometry in peritoneal malignancy patients undergoing cytoreductive surgery

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an established treatment for peritoneal malignancy. A hypercoagulable state in these patients and the associated risk of venous thromboembolism (VTE), remains the most common cause of 30-day mortality. This study aimed to evaluate the prevalence and perioperative factors associated with baseline hypercoagulability detected by rotational thromboelastometry (ROTEM), a point-of-care haemostatic assay, in peritoneal malignancy patients. Methods: A retrospective cohort study was performed in a peritoneal malignancy unit on patients undergoing CRS between 2019 and 2023, who underwent preoperative ROTEM testing. Patients were divided into group A (hypercoagulable) and Group B (normal coagulation). Baseline characteristics, pathology results, operative details and post operative outcomes were reviewed. Univariate and multivariate analysis were used to identify factors associated with baseline hypercoagulability. Results: The 70 patients were included, 23 patients in group A (32.9%) and 47 patients in group B (67.1%). Group A had a lower preoperative haemoglobin (p<0.001), higher platelet count (p<0.001) and median peritoneal carcinomatosis index (33 vs 10, p=0.003). Appendiceal primary was associated with hypercoagulability (47.8% vs 23.4%, p=0.039). Group A required more intraoperative transfusion with red blood cells (p=0.014) but not platelets (p=0.6) or cryoprecipitate (p=0.8). Although group A had a higher incidence of VTE events (30.4% vs 23.4%) this was not statistically significant. Conclusions: Baseline hypercoagulability exists in one-third of patients with peritoneal malignancy and was associated with increased tumour burden and appendiceal primary. The increasing use of ROTEM is a valuable tool for perioperative management of complex peritoneal malignancy patients.

A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery.

Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM®) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM® to reduce blood product utilization during and after neonatal and infant cardiac surgery. We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM® algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM® data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded. The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM® group received fewer platelets (36±12 vs. 49±27 mL/kg, p 0.028) and cryoprecipitate (8±3 vs. 15±10 mL/kg, p 0.001) intraoperatively when compared to the control group. The utilization of ROTEM® may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM® data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.

P65: Predictors of Bleeding with Rotational Thromboelastometry in Patients with a Left Ventricular Assist Device

Purpose: Bleeding events are a significant source of morbidity and mortality in patients with left ventricular assist devices (LVAD). Rotational thromboelastometry (ROTEM) is a form of viscoelastographic testing that provides a real-time analysis of clot initiation, clot strength, and fibrinolysis. There is limited data regarding the use of ROTEM in predicting bleeding events in patients with LVADs post-implantation. Therefore, the purpose of this study is to determine if any component in ROTEM is associated with bleeding events in LVAD patients. Methods: This was a retrospective, single-centered, cohort study of LVAD patients implanted between January 2013 to December 2022 that compared ROTEM values between patients admitted due to bleeding and non-bleeding controls. ROTEM values drawn within 24 hours of separate hospitalizations were included. Patient encounters were excluded for the following reasons: ROTEM drawn after receiving blood or anticoagulant reversal agent, parenteral anticoagulation, or direct oral anticoagulants, and admission related to thrombotic events, index implantation, or device exchange. The primary outcome was to determine if ROTEM values were associated with bleeding events. Results: Of the 327 patient admissions evaluated, 266 patient encounters met inclusion criteria with 59 (22.2%) bleeding events and 207 (77.2%) controls. Of the excluded patients, 28 patients were excluded due to ROTEM drawn after receiving blood or an anticoagulant reversal agent. Baseline characteristics including age, gender, race, ethnicity, device type, last ejection fraction, and indication for implant were similar between groups. Patients admitted for a bleeding event were more likely to have a history of any bleeding event (p=0.01). There was no significant difference seen in the regression analysis evaluating INTEM clot time (p=0.55), INTEM clotting formation time (p=0.45), EXTEM clotting time (p=0.72), FIBTEM clot formation time (p=0.78), and FIBTEM clotting time (p=0.78) for patients experiencing a bleeding event vs those without a bleeding event (table 1). Conclusion: There are no differences in ROTEM values in LVAD patients admitted for bleeding events compared to non-bleeding admissions. Table 1.

ROTEM-GUIDED TRANSFUSION MANAGEMENT FOR ACUTE TYPE A AORTIC DISSECTION: A SINGLE CENTRE EXPERIENCE

ROTEM-GUIDED TRANSFUSION MANAGEMENT FOR ACUTE TYPE A AORTIC DISSECTION: A SINGLE CENTRE EXPERIENCE

The Sensitivity and Specificity of Rotational Thromboelastometry (ROTEM) to Detect Coagulopathy During Moderate and Severe Postpartum Hemorrhage: A Prospective Observational Study

(Int J Obstet Anes. 2022;49:103238) Viscoelastometric hemostatic assays, such as rotational thromboelastometry (ROTEM), offer rapid, point-of-care identification of coagulopathy during postpartum hemorrhage (PPH). Previous studies investigating the use of ROTEM have used a Delta ROTEM device. This study investigates the use of the ROTEM Sigma device, identifying the sensitivity, specificity, and positive or negative predictive values in patients with PPH.

The Use of ROTEM in Liver Transplant Surgeries: A Luxurious Option or a Necessity?!

Blood management in liver transplant surgeries can be challenging. In this article I will address some of the strenuous challenges related to blood management in this patient population and discuss the use of rotational thromboelastometry (ROTEM) to mitigate these challenges. It is well known that patients with liver disease have a rebalanced hemostasis due to the impaired synthesis of both the coagulation factors and pro-coagulant factors. Interestingly, some studies demonstrated an increased endogenous thrombin potential (ETP) in patients with liver cirrhosis [1]. Hence, it is now well known that this group of patients requires special attention when it comes to blood management.

Tranexamic acid administered during cesarean delivery in high-risk patients: maternal pharmacokinetics, pharmacodynamics, and coagulation status

Tranexamic acid is frequently administered for postpartum hemorrhage. The World Health Organization recommends 1 g intravenous dosing, repeated once after 30 minutes for ongoing bleeding. Understanding the pharmacokinetics and pharmacodynamics of tranexamic acid in patients at high risk of postpartum hemorrhage may enable dosage tailoring for optimal antifibrinolysis with minimal adverse events, such as thrombosis or renal cortical necrosis. This study aimed to report tranexamic acid pharmacokinetics and pharmacodynamics after 1 g intravenous dosing during cesarean delivery in patients at risk of hemorrhage. The primary endpoint was tranexamic acid plasma concentration of >10 μg/mL, known to inhibit 80% of fibrinolysis. In addition, the correlation between patient demographics and rotational thromboelastometry coagulation changes were analyzed. In this prospective study, 20 women aged 18 to 50 years, ≥23 weeks of gestation undergoing cesarean delivery with at least 1 major (placenta previa, suspected placenta accreta spectrum, or active bleeding) or 2 minor (≥2 previous cesarean deliveries, previous postpartum hemorrhage, chorioamnionitis, polyhydramnios, macrosomia, obesity, or suspected placental abruption) risk factors for postpartum hemorrhage were recruited. The exclusion criteria were allergy to tranexamic acid, inherited thrombophilia, previous or current thrombosis, seizure history, renal or liver dysfunction, anticoagulation, or category III fetal heart tracing. Tranexamic acid 1 g was administered after umbilical cord clamping. Blood samples were drawn at 3, 7, 15, and 30 minutes and then at 30-minute intervals up to 5 hours. Plasma concentrations were evaluated as mean (standard error). Serial rotational thromboelastometry was performed and correlated with tranexamic acid plasma concentrations. The median age of participants was 37.5 years (interquartile range, 35.0-39.5), and the median body mass index was 28.6 kg/m2 (interquartile range, 24.9-35.0). The median blood loss (estimated or quantitative) was 1500 mL (interquartile range, 898.5-2076.0). Of note, 9 of 20 (45%) received a transfusion of packed red blood cells. The mean peak tranexamic acid plasma concentration at 3 minutes was 59.8±4.7 μg/mL. All patients had a plasma concentration >10 μg/mL for 1 hour after infusion. Plasma concentration was >10 μg/mL in more than half of the patients at 3 hours and fell <10 μg/mL in all patients at 5 hours. There was a moderate negative correlation between body mass index and the plasma concentration area under the curve (r=-0.49; 95% confidence interval,-0.77 to-0.07; P=.026). Rotational thromboelastometry EXTEM maximum clot firmness had a weak positive correlation with longitudinal plasma concentration (r=0.32; 95% confidence interval, 0.21-0.46; P<.001). EXTEM maximum clot lysis was 0% after infusion in 18 patients (90%), and no patient in the study demonstrated a maximum lysis of >15% at any interval from 3 minutes to 5 hours. There was no significant correlation between EXTEM clot lysis at 30 minutes and longitudinal tranexamic acid plasma concentrations (r=0.10; 95% confidence interval,-0.20 to 0.19; P=.252). After standard 1 g intravenous dosing of tranexamic acid during cesarean delivery in patients at high risk of hemorrhage, a plasma concentration of ≥10 μg/mL was sustained for at least 60 minutes. Plasma tranexamic acid levels correlated inversely with body mass index. The concurrent use of rotational thromboelastometry may demonstrate tranexamic acid's impact on clot firmness but not a hyperfibrinolysis-derived trigger for therapy.

Abstract WP117: Post-procedural Screening With ROTEM For Risk Of Hemorrhage Following Revascularization Therapy For Acute Ischemic Stroke

Introduction: Hyperfibrinolysis is associated with intracerebral hemorrhage (ICH) after the use of tPA for acute ischemic stroke (AIS). Point-of-care Rotational ThromboElastoMetry (ROTEM) testing may rapidly detect hyperfibrinolysis and identify AIS patients at high risk for hemorrhage. Hypothesis: Evidence of fibrinogen depletion on ROTEM will accurately predict bleeding following revascularization therapy for AIS. Methods: We reviewed medical records of AIS patients who underwent revascularization therapy between 2019-2020. All patients underwent ROTEM testing post-procedure to facilitate targeted blood product transfusion should hemorrhage occur. However, transfusion was not performed prophylactically. Repeat imaging with dual-energy CT was performed within 24 hours. A quality control registry of all AIS patients who undergo revascularization is maintained for purposes of Joint Commission certification. All variables, including ROTEM values and occurrence of intra- and extracranial hemorrhage, were entered prospectively. We examined the predictive value of a FIBTEM-A10 &lt;10mm for post-procedural hemorrhage. Results: A total of 52 patients were included. Median age was 68 years (Interquartile Range, IQR 60-83), and median admission NIHSS was 16 (IQR 10-20). Thirty-four patients (65%) received tPA, 46 (88%) received mechanical thrombectomy, and 28 (54%) received both. Median post-procedure FIBTEM-A10 was 16mm (IQR 14-22); 5 patients had values &lt;10mm. Overall, 19 (37%) suffered radiographic ICH, 5 (10%) symptomatic ICH, and 3 (6%) extracranial hemorrhage. FIBTEM-A10 &lt;10mm had sensitivity 17% and specificity 97% for any post-procedural hemorrhage. For symptomatic ICH, sensitivity was 0% and specificity 89%. Conclusions: The use of ROTEM to identify hyperfibrinolysis following AIS revascularization therapy achieved poor sensitivity and high specificity for prediction of any post-procedural hemorrhage, but was inaccurate for the prediction of symptomatic ICH.

Use of rotational thromboelastometry to predict the outcome of COVID-19 patients: A retrospective observational study.

Background and Aims:The hypercoagulability occurring in COVID-19 patients is detected only by Rotational thromboelastometry (ROTEM). However, the benefit of performing ROTEM in the management of disease and predicting the outcome of COVID-19 patients is yet to be established.Material and Methods:The data of 23 critically ill and 11 stable COVID-19 adult patients were extracted from the hospital information system admitted between July and August 2020 and patient charts and analyzed retrospectively. The critically ill patients were divided as a survivor and non-survivor groups. The Intrinsic pathway part of ROTEM (INTEM) and Fibrinogen part of ROTEM (FIBTEM) were performed on day 0 for both critically ill and stable patients, and on day 10 for critically ill patients. The statistical package for social science (SPSS) version 26 was used for statistical analysis.Results:The median FIBTEM amplitude at 5 min (A5) and maximum clot firmness (MCF) were elevated in both stable and critically ill patients (24 vs 27 mm, P = 0.46 and 27.5 vs 40 mm, P = 0.011) with a significant difference in FIBTEM MCF. But there was no significant difference between number of survivors and non-survivors with FIBTEM MCF >25 at day 0 and day 10.Conclusion:The Hypercoagulability state as detected by ROTEM parameters at day 0 and day 10 had no association with the outcome (mortality) of critically ill COVID-19 patients. Hence it cannot be used as a prognostic test. The increasing age, comorbidities and D-dimer values were associated with a poor prognosis in COVID-19 patients.

Transfusion management of trauma from the 2019 El Paso mass shooting incident.

Mortality rates, transfusion ratios, trauma management logistics, and assault characteristics from the El Paso mass shooting incident (MSI) are evaluated in comparison to other MSIs. In 2019, El Paso, TX experienced the eighth-deadliest MSIs in modern US history. In this 21st mass killing in the United States of 2019, 19 people died immediately, and four of 27 injured, later died from ballistic injuries. We examined the victims' injuries, pre-hospital treatments, transfusions, rotational thromboelastometry (ROTEM) interpretation, tranexamic acid (TXA) use, and compared El Paso's outcomes with other MSIs. Fifteen casualties were treated for bullet injuries at University Medical Center (UMC). Three were in critical condition; one died during surgery. Of the remaining victims, two were guarded, and the remaining ten in stable condition. Anatomic trauma locations included chest, abdomen, hip, breast, thigh and arm. Haemostatic agents and TXA were administered to arriving patients. Seven casualties receiving blood products were administered 95 units at UMC (45 red blood cells [RBC], 38 fresh frozen plasma [FFP], 8 platelets and 4 cryoprecipitate). ROTEM guided mass transfusion decisions in three patients. Out of seven MSIs reviewed, El Paso had the highest mortality rate (50.0%) and lowest RBC:FFP:admission ratio (1.18 at UMC). We report the greatest proportion of transfusions per admission for an MSI and are first to discuss ROTEM roles to guide transfusion and manage coagulopathy during an MSI. This case highlights the severity and impact of MSIs on victims and requirements to follow established transfusion protocols with adjunct use of ROTEM, TXA and haemostatic agents.

Use of rotational thromboelastometry to predict hemostatic complications in pediatric patients undergoing extracorporeal membrane oxygenation: A retrospective cohort study

BackgroundThe incidence of hemostatic complications in pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) is high. The optimal anticoagulation strategy in children undergoing ECMO is unknown. ObjectivesTo study the association between hemostatic complications, coagulation tests, and clinical parameters in pediatric patients undergoing ECMO and their effect on survival. MethodsWe performed a retrospective cohort study of pediatric patients undergoing centrifugal pump ECMO. Collected data included patient characteristics, risk factors, and coagulation test results. Statistical analysis was done using logistic regression analysis for repeated measurements. Dependent variables were thrombosis and bleeding, independent variables were rotational thromboelastometry (ROTEM), activated partial thromboplastin time (aPTT) and antifactor‐Xa assay (aXa) results, ECMO duration, age <29 days, sepsis and surgery. ResultsSeventy‐three patients with 623 ECMO days were included. Cumulative incidences of thrombosis and bleeding were 43.5% (95% confidence interval [CI], 26.0%‐59.8%) and 25.4% (95% CI, 13.4%‐39.3%), respectively. A lower maximum clot firmness of intrinsic ROTEM (INTEM; odds ratio [OR], 0.946; 95% CI, 0.920‐0.969), extrinsic ROTEM (OR, 0.945; 95% CI, 0.912‐0.973), and INTEM with heparinase (OR, 0.936; 95% CI, 0.896‐0.968); higher activated partial thromboplastin time aPTT; OR, 1.020; 95% CI, 1.006‐1.024) and age <29 days (OR, 2.900; 95% CI, 1.282‐6.694); surgery (OR, 4.426; 95% CI, 1.543‐12.694); and longer ECMO duration (OR, 1.149; 95% CI, 1.022‐1.292) significantly increased thrombotic risk. Surgery (OR, 2.698; 95% CI, 1.543‐12.694) and age <29 days (OR 2.242, 95% CI 1.282–6.694) were significantly associated with major bleeding. Patients with hemostatic complications had significantly decreased survival to hospital discharge (P = .009). ConclusionThe results of this study help elucidate the role of ROTEM, aPTT, anti–factor Xa, and clinical risk factors in predicting hemostatic complications in pediatric patients undergoing ECMO.

ROTEM Testing for Direct Oral Anticoagulants.

Direct oral anticoagulants (DOACs) are increasingly used worldwide for the prevention of stroke in patients with atrial fibrillation and to prevent or treat venous thromboembolism. In situations such as serious bleeding, the need for urgent surgery/intervention or the management of a thromboembolic event, the laboratory measurement of DOACs levels or anticoagulant activity may be required. Rotational thromboelastometry (ROTEM) is a viscoelastic hemostatic assay (VHA) which has been used in emergencies (trauma and obstetrics), and surgical procedures (cardiac surgery and liver transplants), but experience with this assay in DOACs-treated patients is still limited. This article reviews the use of ROTEM in the setting of DOACs therapy, focusing on DOACs-associated bleeding and the use of this VHA for the management of reversal strategies for DOACs-associated anticoagulation.

The Debate ROTEMs on–the Utility of Point-of-care Testing and Fibrinogen Concentrate in Postpartum Hemorrhage

(Anaesthesia. 2020;75:1247–1251) A 2019 report by McNamara et al revealed 4 years of data from their use of rotational thromboelastometry (ROTEM) to help guide the treatment of major obstetric hemorrhage (PPH; defined as &gt;1500 mL estimated blood loss with continued bleeding or evidence of shock). Their proposed ROTEM-guided strategy for transfusion called for fibrinogen concentrate to treat coagulopathy in place of fresh frozen plasma (FFP) and/or cryoprecipitate. The ROTEM-based protocol was compared to the previous care standard, which included a shock pack containing four units of FFP, four units of packed red cells, and one pooled unit of platelets. The authors of the original report noted that use of the ROTEM-guided transfusion algorithm had a statistically significant reduction in the number of units and total volume of blood products transfused. This, in turn, pushed them to argue that not all women who experience major PPH are coagulopathic suggesting that perhaps goal-directed transfusion guided by point-of-care (POC) testing is more justified than the routine use of transfusion shock packs in these cases. This issue of Clinical Consequences aims to discuss several controversies: use of fibrinogen concentrates in PPH-related coagulopathy, utility of POC testing in obstetrics and impact of POC testing in guidelines for PPH management; and finally the McNamara et al paper’s likely influence on clinical practice.

Rotational Thromboelastometry Derivative Fibrinogen-Platelet Ratio Predicts Thrombosis in Microsurgery.

Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability. We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR). Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific. Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.

Thromboelastometry, Thromboelastography, and Conventional Tests to Assess Anticoagulation During Extracorporeal Support: A Prospective Observational Study.

Optimal anticoagulation monitoring in patients with extracorporeal membrane oxygenation (ECMO) is fundamental to avoid hemorrhagic and thromboembolic complications. Besides conventional coagulation tests, there is growing interest in the use of viscoelastic hemostatic assays (VHA), in particular of tromboelastography (TEG). Evidence on the use of rotational thromboelastometry (ROTEM) is lacking in this setting. The aim of the study was to evaluate ROTEM as a tool for assessing hemostasis during ECMO, by comparing it to TEG and conventional coagulation assays. We conducted a prospective, observational, single-center study on adult patients on ECMO support anticoagulated with unfractioned heparin (UFH). Kaolin reaction time (R, min) for TEG and INTEM clotting time (CT, sec) for ROTEM were analyzed and compared with conventional coagulation tests. In the study period, we included 25 patients on ECMO support (14 V-A and 11 V-V); 84 data points were available for the analysis. Median UFH infusion rate was 15 [11-18] IU/min/kg. Median values for activated partial thromboplastin time (aPTT) ratio, Kaolin TEG R time, and INTEM CT were 1.44 [1.21-1.7], 22 [13-40] min, and 201 [183-225] sec, respectively. INTEM CT (ROTEM) showed a moderate correlation with standard coagulation tests (R2 = 0.34 and 0.3 for aPTT and activated clotting time (ACT), respectively, p < 0.001). No significant correlation was found between INTEM CT and Kaolin R time (R2 = 0.01). Further studies are needed to identify an appropriate anticoagulation target for ROTEM during ECMO.

Combined Use of Rotational Thromboelastometry (Rotem) and Platelet Impedance Aggregometry (Multiplate Analyzer) in Cyanotic and Acyanotic Infants and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass: Subgroup Analysis of a Randomized Clinical Trial

Few studies have investigated the Multiplate platelet function analyzer in pediatrics. The authors evaluated Multiplate combined with Rotem in terms of guiding platelet transfusion after pediatric cardiac surgery with cardiopulmonary bypass (CPB). The authors further compared coagulation parameters between cyanotic and acyanotic patients. Subgroup analysis of a randomized clinical trial. Tertiary hospital. Patients weighing between seven and 15 kg. None. Rotem and Multiplate tests were performed (1) after anesthesia induction, (2) upon CPB separation, and (3) upon intensive care unit arrival. Among a total of 59 subjects, 9 patients required platelet transfusion. In multivariate linear regression, analysis EXTEM maximum clot firmness upon CPB separation was associated with the volume of transfused platelets (regression coefficient = -0.348 [95% confidence interval -1.006 to -0.028]; p = 0.039). No such association was found for the Multiplate test. Acyanotic and cyanotic heart disease were present in 32 and 27 children, respectively. There were no significant differences between these two groups in terms of platelet count and function. Postoperative blood loss was significantly higher in the cyanotic group compared with the acyanotic arm (p = 0.015; difference [95% confidence interval -2.40 {-4.20 to -0.60}]). There were no differences between groups regarding transfusion of allogeneic blood products. This study showed that Rotem, but not Multiplate results, were associated with platelet transfusion in pediatric cardiac surgery with no intake of platelet inhibitors. The usefulness of combining these tests in platelet transfusion decision-making needs to be evaluated in larger populations.

Standard and derived rotational thromboelastometry parameters for prediction of disseminated intravascular coagulation in septic patients.

: Waiting for lab tests results for the calculation of disseminated intravascular coagulation (DIC) scores leads to unwanted delays in diagnosis. The use of rotational thromboelastometry (ROTEM) for this purpose would allow for a more rapid DIC diagnosis at the bedside. The aim of this study was to assess the ability of standard ROTEM parameters and calculated parameters from the ROTEM velocity curve to predict DIC. The retrospective observational study included 97 septic patients. Japanese Association for Acute Medicine score was used for DIC diagnosis and whole-blood ROTEM was performed at study inclusion. Univariate analysis revealed delayed coagulation initiation and propagation and reduced clot firmness and maximum elasticity in DIC patients compared with patients without DIC. To adjust for confounders, multivariable logistic regression models were created and fibrinogen levels, prothrombin time and ROTEM parameters such as maximum clot firmness, maximum clot elasticity (MCE) and total thrombus formation [area under the curve (AUC)] were identified as significant predictors of DIC. According to receiver operating characteristics analysis, MCE and total thrombus formation (AUC) were the most useful ROTEM parameters for DIC prediction. MCE less than 158 (73% sensitive, 80% specific) and AUC less than 6175 mm × 100 (73% sensitive, 76% specific) predicted DIC in septic patients. Both standard and derived ROTEM parameters are useful for rapid DIC prediction in septic patients, allowing the timely identification of patients with higher mortality risk which might benefit from additional therapies. Further studies are needed to assess the clinical relevance of these findings.

Is major burn injury associated with coagulopathy? The value of thrombelastometry in the detection of coagulopathy in major burn injury: A prospective observational study.

The coagulation status of burn patients is generally impaired and is a major factor of the deteriorating burn patients' overall situation. In trauma and other patient groups, the differential diagnosis of coagulation impairment has been largely improved by the use of rotational thromboelastometry (ROTEM®). The aim of this prospective observational study was the differentiated observation of coagulopathy in severely burned patients using standard parameters and ROTEM® thrombelastometry during the relevant stages of burn disease. Twelve patients that sustained at least 20% third degree burns of total body surface area (TBSA) were included in the study. Standard and ROTEM® coagulation analyses were performed on admission and then twice daily during the first 14 days following burn trauma. Although the initial assessment of DIC was similar for both standard labs and ROTEM® measurements, more patients were detected to be in a state of worsening coagulation status for a longer time in ROTEM® than in standard measurements. In addition, one patient was rated in to be in decompensated DIC for 3 days according to ROTEM® measurements, while no patient was rated to be in a decompensated DIC based on standard parameters. This study points towards a more complex picture and higher occurrence of DIC in burn patients when thrombelastometric measurements like ROTEM® are taken into account in addition to standard coagulation parameters.

Use of Rotational Thromboelastometry in Liver Transplantation Is Associated With Reduced Transfusion Requirements.

Increased transfusion requirements in liver transplantation have been reported to be associated with worsened outcomes, more frequent reinterventions, and higher expenses. Anesthesiologists might counteract this through improved coagulation management. We evaluated the effects of rotational thromboelastometry on transfusion and coagulation product requirements and on outcome measurements. Patients who were 14 years or older and who were undergoing liver transplant at Hannover Medical School between January 2005 and December 2009 were included in this retrospective analysis. Demographic, clinical, and laboratory data, use of rotational thromboelastometry, intraoperative need for blood or coagulation products and antifibrinolytic substances, and clinical course were recorded. Correlations were examined using appropriate statistical tests. Our study included 413 patients. Use of rotational thromboelastometry was associated with less frequent intraoperative administration of red blood cell concentrates, fresh frozen plasma, platelet concentrates, prothrombin complex concentrates, and antithrombin concentrates (all P < .05). In addition, univariate and multivariate tests showed that rotational thromboelastometry was correlated with decreased need for red blood cell concentrates and fresh frozen plasma (all P < .05). Intraoperative administration rates of antifibrinolytic substances and fibrinogen concentrate were significantly increased in patients who received rotational thromboelastometry monitoring (both P < .05). However, use of rotational thromboelastometry was not associated with massive transfusion rates (> 10 units vs less), clinical outcome, or length of stay in the intensive care unit (all P > .05). Use of rotational thromboelastometry during liver transplant may reduce the need for intraoperative transfusion and coagulation products. Relevant effects of rotational thromboelastometry on patient outcomes or lengths of stay in the intensive care unit could not be ascertained. However, readjustment of therapeutic thresholds may improve the clinical impact.